Behind the Pleasure: Sexual Decision-Making among High-Risk Men in Urban Vietnam

Published by Family Health International (FHI), this 84-page report is based on the premise that male clients of sex workers are a bridge population linking female sex workers to the general population, yet their role in HIV prevention has been overlooked in Vietnam in favour of focusing on prevention programmes for sex workers.

As detailed here, in December 2004, FHI hosted a stakeholder meeting in Hanoi of national and international non-governmental organisations (NGOs) and United Nations agencies to discuss ways to increase male involvement in HIV/AIDS prevention. The discussion focused on engaging male clients of sex workers to become active in preventing HIV transmission to themselves and their wives or girlfriends. Then, from April to June 2005, a research team comprised of FHI staff, consultants, representatives of NGOs and national social research agencies conducted a qualitative study of male clients of sex workers and other key informants. Candidates included men at high risk of purchasing sex, married women, and entertainment establishment owners. Researchers facilitated 18 meetings (6 each in Hanoi, Haiphong, and Ho Chi Minh City); in all, 324 candidates were interviewed. A rapid, participatory method called Community Dialogue Meetings (CDM) centred around larger-than-normal group interviews based on focus group discussions (FGDs) in the form of meetings lasting 3-4 hours. "Larger groups and longer meeting times allowed for a more detailed level of inquiry, participatory activities, and the ability to include discussion topics thought to
be relevant by participants."

This report details the findings of the study and documents findings, divided into the following categories:

• Male behaviour patterns and group norms - Research participants estimated that 70-90% of men they knew have sex outside of marriage...
• Process of sexual decision making - Four key factors affect male sexual decision-making processes: drinking alcohol, financial status, peer acceptance, and the ability to refuse commercial sex.
• Reasons for frequenting sex workers - Married and unmarried men frequent sex workers because: 1) they are unhappy with family life, 2) want to try something new, and 3) to strengthen bonds with friends, co-workers and bosses.
• What makes a "real" man? - "Sexual capacity and experience are key factors in evaluating men as manly."
• The positive deviant - "Most men had difficulty imagining having sex with only one woman."
• Male responsibility - "Sex outside of marriage is considered entertainment, and not viewed as irresponsible....The men interviewed do not take responsibility for their sexual actions, stating many reasons for going out for commercial sex..."
• What men and women talk about in a group - "All men and married women discuss sex when they are in same-sex groups..."
• Sexual dialogue in the home - "Domestic communication is difficult and spouses rarely discuss sex..."
• Understanding HIV/AIDS - "HIV/AIDS transmission and prevention facts were widely understood by respondents..."
• Current sources of information on HIV/AIDS - Men interviewed cited a range of potential and preferred passive and active sources of information about HIV/AIDS ranging from TV, newspapers, friends and relatives to counseling centers, hotlines and the internet.
• Awareness & participation in community-based activities - Men in this study reported little access to, or participation in community-based activities...
• Participant recommendations - "Men did not want the typical HIV messages, particularly preaching-style advertisements or slogans. They recommended that the tone be light and funny or something more substantial. Any media, from TV to posters and banners, needed to be attractive so that it would catch attention and stand out in the media and
  public environment....Men recommended that any messages must reach them everyday; however,
  messages and media need to change frequently to avoid boredom."
• Conclusions and recommendations
  1. Programming designed specifically for men needs to be increased throughout the entire continuum of HIV and AIDS, from prevention to care and treatment.
  2. Develop and implement a mass media campaign encouraging men to reduce the frequency of purchasing commercial sex.
  3. A diverse array of communication channels should be used to promote accurate
     assessments and perceptions of risk along with preventive behavioural norms among
     men. (A first step to increasing personal risk perception, recommended by many of the men in this study, is to "make AIDS real" through use of real stories of real people in Vietnam who are living with HIV.)
  4. Communication that models images of real men making positive decisions may help men feel refusal is both acceptable and possible. Men may also benefit from skills building in assertiveness and identification of personal values that are aimed and increasing self-confidence and esteem.
  5. Provide materials and media programming that can act as triggers to assist young, unmarried couples and currently married men and women in communicating about sex and sexual choices.

Click here to access a related peer-reviewed summary on the Health e Communication website, and to participate in peer review.